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APPLICATION <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> EN AJII DIVISION <br /> 445 N A f,INE (209)49° 2'"'^ .� <br /> P O O 0 TO TON, CA $ (# � <br /> n ERM RfiS 1 YEAR FSH( 1A D��SJ� le zq( <br /> H (Complete in Triplica )p/� Jj <br /> Application L hereby mad d�t�`'�l/ oaquln County for a permit to construct ngdPof'?�pa#lt tF� w�4 w__�... ee___ <br /> application County <br /> Pude in ealthlance cvithes. inn Joaquin County Ordinance No. and 1B6$ a[tA the Rule) aqd R lotions Jof Su <br /> Joaquin Count(y�Public Nenl�ltrhGBenrvl�c{ee/.,AFGN� a.0 7-0 �� -V.7 � NV jjtj (Q 7 <br /> Job Address SVC <br /> „CA�"/�r r-R 9 /7Ge`,t�R,�yR�j. C,ry <br /> Owner's Nome �(� I AMOV /`r7lAdress _ /17�� R�✓�<z Deuce �F�-ea1, A� <br /> /�p�- �s�-J4 ate. <br /> Coniraclor 61cs Address,(�Z _ /�10�License No. Phone <br /> TYPE OF WELL/PUMP: NEW WELL O i ELL REPLACEMENT n DESTRUCTION O Out of Service Well ❑ <br /> PUMP INSTALLATION O SYSTEM REPAIR ❑ OTHER O Monitoring Well C7 <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE _ <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS _ <br /> _INTENDED USE TYPE OF WELL ' PROBLEM AREA CONSTRUCTION SPECIFICATIONS 1 <br /> I I Industrial O Open Bottom ❑ Manteca Dia. of Well Excavation .. .Dia, of Well Casing <br /> r I Domestic/Private ❑ Gravel Pack ❑ Tracy i Type of Casing__ Specifications <br /> I Public 11 Other Il Delta Depth of Grout Seal Type of Grout <br /> I I Imgatwn __ Approx. Depth I I Eastern Surface Seal Installed by <br /> Paper Work Done O Type of Pump H.P. _ State Work Dona_ 5is 'Well Destruction ❑ Wall Diameter Sealing Material i Depth <br /> Depth Tiller Material A DepthTYPE OF SEPTIC WORK: NEW INSTALLATION i I REPAIR/ADDITION I I DESTRUCTION I I (No se tic system rmimed it p pe public se <br /> MQ /�1�.I�I T available within 200 Iset.) <br /> Installatio��grva:O�idehce�rCommarcial_ ONror _ /'_ <br /> Number of living units: _ Number of bedrooms <br /> Character of soft to a depth of 3 feet: __. Water table depth <br /> SEPTIC TANK ❑ Typo/Mfg Capacity No. Compartments <br /> PKG. TREATMENT PLT. O Method of Disposal <br /> Distance to nearest: Well _ Foundation Property Line , <br /> LEACHING LINE ❑ No. 6 Length of lines .'Total length/site <br /> FILTER BED ❑ Distance to nearest: Well __. Foundation Property Lina i <br /> SEEPAGE PITS 11 Depth _Site _.� _ Number <br /> SUMPS U Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS ❑ <br /> 1 hereby certify that I have prepared this application and that the%i ork will be dune in accordance with San Joaquin county ordinances, stale lows, and <br /> rules and regulations of the Sen Joaquin County <br /> Home owner or licensed agent's signature candies the following: 'I comity that in the padormance of the work for which this permit is issued. 1 shell not <br /> employ any person in such manner as to become subject to worknVn's compensation laws of California.” Contractor's hiring or sub-contracting signature <br /> c"fiss the following: "I comity that in the performance o1 the work for which this permit is issued, I shall employ persons subject to workman's compensa <br /> tion laws of Calif nla." <br /> The applicant t call for II quked,inspections. Complete drawing on reverse side. <br /> Signed x Title: V V. / Date: . <br /> FOR DEPARTMENT USE ONLY 7 Q <br /> Application Accepted by t �.��'��_. ._ Data f �� �3 rax 21 '-'/ov �1z <br /> Pit or Grout Inspection by Dotea Final Inspection by A Data�j] <br /> T <br /> Additional Comments: ffiL <br /> 1ppl D ant - Return all It copies to: San Joaquin County Public Health Services <br /> Environmental Health P«rmit/Servicer, <br /> 445 N San Joaquin, P O Box 2009, Stkn, CA 95201 <br /> -'- INFO AMOUNT DUE AMOUNT REMITTED ASN RECEIVED BY DATE PERMIT NO, <br /> f�nNlafV.freer / O ��Y }e [CV , 3 <br /> [M It■ <br />